Haematologic adverse events
following Immunisation to COVID-19

Use this online form to report:
thrombotic events with thrombocytopenia
- a new or relapsed case of immune thrombocytopenia (ITP)
                                                                         ...following immunisation to COVID-19.

This form does not replace the need to report suspected adverse events following immunisation via the Yellow Card scheme.

If you have already reported using the Yellow Card system and have received a link to this proforma to provide additional information, then please proceed below.

If you have not yet reported to MHRA, then complete this proforma. On the final screen, a summary of your responses will be displayed which you can cut/paste into the online Yellow Card form. You will then be given a MHRA report number which you willl need to enter before final submission.

This system is a collaboration between Public Health England, NHSE and MHRA. PHE is the data owner and controller, and is authorised under Regulation 3 and 7 of the Health Service (Control of Patient Information) Regulations 2002 to collect the data (including personal identifiables [PII]) requested below. By entering your details as Reporter, you consent to further contact by PHE/MHRA/NHS representatives if required.


  Page 1/7  
Snap Survey Software